Provider Demographics
NPI:1063922771
Name:ELLIS, ANTHONY (NP)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44280 REVERE PL
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5902
Mailing Address - Country:US
Mailing Address - Phone:510-387-7011
Mailing Address - Fax:
Practice Address - Street 1:2105 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1425
Practice Address - Country:US
Practice Address - Phone:408-947-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2017-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily